Ethiopia: Cholera Outbreak Threat in Addis

Melese Kebede was rushing to get his wife timely treatment when Fortune met him in the early hours of Wednesday, July 6, 2016. She was in a critical health condition; horribly weak from her unstoppable loss of fluid through vomiting and diarrhoea. He was incredibly concerned that she might have potentially contracted what he and his neighbours had been discussing throughout the week.

Prior to her case, health workers had visited their locality to inform residents of the emerging health concerns and recommended precautions to avoid contamination. This could, however, not save his wife from infection.

To his dismay, the first health post sent him to a Cholera Treatment Centre (CTC) at Mikililand Health Centre.

Melese and his wife have lived in the Kolfe Qeranio district, Wereda 13, for the past 27 years. This may well be a demanding time for him, as he is challenged with his low income. He works as a carpenter, with no permanent income.

He was referred to the Mikililand Health Centre – where the first Cholera case was reported on July 6, 2016.

His wife, Alemitu Mehertu, 65, was rushed to the centre that specialises in cases of her kind.

The separate CTC is split off from the rest of the Health Centre, in order to ensure that cases of acute watery diarrhoea (AWD) do not lead to further contamination among patients and staff.

The station where Melese’s wife first visited, which is a public health station, was too late to discover that she was actually affected by AWD, and mistakenly bedded her together with other patients with completely different cases.

Though the first case of death due to AWD was reported on July 2, 2016 – with media alarmed by the case, despite it being managed by the government – the incidences have continued to grow. This is what led to the station talking the decision to have a separate unit to treat Cholera cases, two weeks ago.

A tented CTC is located just inside the health station, where it is isolated from the rest of the compound inside.

Inhabited by close to half a million people, the Kolfe Qeranio district has three health centres, two run by the government and the other by NGOs. There are also over 80 private clinics at different levels and a hospital.

The station located in Wereda 13 is public owned, and has been referring patients on to Mikililand.

“We decided to refer her situation of AWD, as it is a common synonym of Cholera,” said an expert.

Cholera is an infectious disease characterised by intense vomiting and profuse watery diarrhoea, which rapidly leads to dehydration and often death. It is caused by infection with the bacteria Vibrio-cholerae, which may be transmitted via infected faecal matter, food or water – as defined by medicine nets, an electronic technical dictionary.

The husband agreed that her situation was exactly as defined above.

By the time they get to the Mickililand, her situation left no room for rechecking. She was close to being unconscious, and frighteningly frail. The health officers automatically admitted her to the specialised centre.

In Kolfe Qeranio there are two specialised CTCs, one in each government-run health centre. These are among the 24 centres established across the 10 district that have been alerted to identify cases.

It was almost one month since the Ministry of Health (MoH) reported the frequent occurrence of cases of AWD in parts of the capital, calling for a precautionary preventive measures from the public. By that time, 25 cases of AWD had been identified across the city. These statistics have now leapt up to a little over 2,000.

It was never referred to as an outbreak in an official manner, which would have been followed by an emergency medical shipment from international agencies. The WHO standard defines a Cholera outbreak when 10 to 20 cases are reported and confirmed.

Two weeks after the alarm, sectoral engagements with other players, like the media, continued, indicating that the situation is getting no better, but demands a more concerted effort.

“Communication and framing was careful not to alarm the public, mellowing down the incidences arising, rather than announcing a full-fledged outbreak and a public health emergency,” a health expert, working in one of the international development partners on the areas of health, told Fortune.

The city has already established a command post to oversee the effort. The post, presided by Mayor Diriba Kuma, comprises institutions such as the Addis Abeba Water & Sewerage Authority, code enforcement officers a.k.a Denb askebari and the Police.

In response to the outbreak of acute diarrhea in Addis Abeba, the city administration’s Food, Drugs & Health Bureau, in cooperation with other bureaus such as Culture & Tourism, Trade and Health bureaus as well as the Police Commission and rules enforcement office, has shouts down 114 business establishments, in addition to 32 butcheries and five private clinics. A volume of of 4,800Kg food stuff, 4,500Kg of fish and 8,000ltr drinks were destroyed.

Despite the efforts, numbers are continuing to follow an upward trajectory.

So far, six deaths have been officially confirmed in the capital. The number of cases is reported to be as high as a thousand plus, according to unconfirmed sources.

For Melese and his neighbours, having an upset stomach and diarrhoea is not an issue of discussion – particularly when it happens with their kids. The number of adults and the issue in the media has alarmed them.

In 2010, Kolfe Qeranio territory was the only one affected by officially recognised higher indices of AWD.

The high population is picked as the first factor making it vulnerable to the rainy season’s floods and sewerage outflow.

A shopkeeper near to Mikililand told Fortune that most who visited the centre with similar health concerns came from areas such as Ayer Tena and Alem Gena, rather than nearby localities. The station, in addition to giving basic services, is now treating AWD-affected people from other areas. The first confirmed cases of AWD were reported in this district.

“So far, I did not hear of anyone affected with 2AWD from our blocks,” said the shopkeeper. “Rather they came from far away.”

The outbreak mostly affected two districts – Kolfe and Addis Ketema. The latter is known for its densely settled population, with 33,970 people within just a one-kilometre square radius. In this respect, the outbreak may well have started from a river in the Kolfe district, which flows way down to southern parts of the capital in the Aqaqi Qality district.

In June 13, 2016, out of 22 confirmed cases, the Addis Ketema and Kolfe districts reported five each, while the rest of the districts reported just one to three. The city Health Bureau has already identified 26 weredas that are considered to be vulnerable to the outbreak across 10 districts, with the majority located in Kolfe.

The same report by the WHO has pointed to the fact that the exact source of the outbreak having not been identified presents a challenge.

“We are not going to disclose latest figures on the outbreak, because it may create a panic among the public,” Mulugeta Admassu told Fortune.

The Bureau is now working with UN agencies, who are assisting the efforts by supplying medicines and expertise. Close to 1,000 health extension workers (HEWs) are said to have been distributed across the city.

Similar cases of citywide outbreak occurred back in 2005 and 2007.

To curb the impacts, it has been suggested that the WHO Cholera Guideline is to be implemented. Those who are suspected to have been exposed to the bacteria that causes the disease have to be treated with chemicals used for this purpose. Not only that, the guideline insisted that all materials have to be disinfected.

In Melese’s case, he missed out on being cleaned with a chemical after he brought his wife to the first station.

“We didn’t know that his wife’s case was AWD,” said the health officer.

After almost three days, he was ordered by physicians at the CTC to take his wife back.

“They said, she is now in a better condition, but still her resistance is not good,” said Melese. “They also told me that the fact that newly affected individuals are coming to the centre might affect those already recovered.”

Later, he was preparing to take his wife back home, but her illness resurfaced and now she is in intensive care at the CTC.

When his wife’s case was confirmed, it was the first, but now other new cases have emerged within two days. One, he said, was someone who lives just a few metres from his house. In the CTC, where his wife being treated, he has witnessed close to a dozen patients with the same sickness being treated.

This doesn’t include additional patients in another part of the CTC, who are at different stages of treatment.

As part of its programme to inform the public, one million brochures are being distributed, 400 forums were prepared and close to 1,000 individuals from religious institutions and five-in-one cells were consulted.

“Given the continuous rainy season, numbers may escalate,” said Mulugeta.

In January of this year, the WHO reported that heavy rains caused by El Nino will cause flooding in East Africa, with an associated health risk. Back then, a Cholera epidemic with more than 12,000 cases was reported in Tanzania. The report also indicated that it may spread, and other countries will experience disease outbreaks. The Tanzanian Cholera outbreak was the largest since 1997-1998, which had over 40 000 reported cases. The outbreak has also been reported in border towns of Eritrea and Ethiopia.